Referral Form 2026 - Lily of the Valley

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Refer A Client

Lily of the Valley provides Home Care Services and Recuperative Care, including skilled nursing, personal care, and support with daily living.

Use this secure referral form to submit client information for review. A team member will contact you to confirm eligibility, clarify needs, and coordinate next steps.

If you have urgent questions, please call our office at [952-846-7885].

Referral Source Information

Referring Agency/Hospital/Organization(Required)

Referrer Name(Required)

Referrer Phone(Required)

Referrer Email(Required)

Date of Referral(Required)

Client Information

Provide basic information about the client being referred.

Client Full Name(Required)

Date of birth(Required)

MM slash DD slash YYYY

Gender(Required)

Client Address (if known)(Required)

Street Address City State ZIP Code

Client Phone(Required)

Emergency Contact Name(Required)

First Last

Emergency Contact Phone(Required)

Preferred Language(Required)

Interpreter Needed?(Required)

Program Requested

Select the program(s) you are referring the client for.

Programs(Required)

Home Care Services

Recuperative Care Services

Home Care Services Needed(Required)

Skilled Nursing and Clinical Needs

Indicate any skilled nursing or clinical needs so we can determine appropriate placement and staffing.

(Required)

Wound care

Medication administration

Medication management

Vital signs monitoring

Diabetes care

Catheter care

Ostomy care

Other skilled nursing needs

Medical Information

Provide relevant medical information to support safe and appropriate care planning.

Primary Diagnosis(Required)

Secondary Diagnosis

Recent Hospitalization Facility

Admission Date

MM slash DD slash YYYY

Discharge Date

MM slash DD slash YYYY

Current medications (list or upload on the documents section(Required)

Upload medications here

Max. file size: 1 GB.

Functional Status and Activities of Daily Living (ADLs)

Tell us about the client’s functional abilities and support needs.

Mobility (Select One):(Required)

Independent

Uses cane

Uses walker

Uses wheelchair

Needs assistance with mobility

ADLs(Required)

Bathing

Dressing

Grooming

Toileting

Eating

Transfers

Medication reminders

Cognitive Status(Required)

Alert and oriented

Memory impairment

Needs redirection

Wandering risk

Behavioral and Psychiatric History (Awareness Only)

Lily of the Valley does not provide psychiatric or substance use treatment. The information below is collected for safety, placement appropriateness, and care coordination only.

Psychiatric diagnosis (if known)(Required)

Behavioral concerns (if any)(Required)

Substance use history (if relevant)(Required)

Current psychiatric medications(Required)

Connected to mental health services?(Required)

Yes

Social and Environmental Information

Share any social or environmental factors that may affect care or placement.

Current housing status(Required)

Support system (family, friends, case manager, etc.)(Required)

Cultural or spiritual considerations(Required)

Safety concerns(Required)

Any known risks to staff or others(Required)

Documents Upload

You may upload any available documents to support this referral.

Files

Hospital discharge summary

Medication list

CSP

Support plam

MN Choice Assessment

Face sheet

Guardianship or POA documents

Additional Notes

Additional information or special instructions

This field is hidden when viewing the form

Terms and Conditions(Required)

Terms and conditions placeholder.

I agree to the terms and conditions.

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We accept the following insurances: